Forum - Questions & Answers

May 5th, 2010 - recyh

RN/MA documenting Exam/MDM

I am aware the documentation guidelines state that the ancillary staff is allowed to document the ROS and PFSH sections and my MAC has made it clear that the physician is required to document the HPI. However, are there any guidelines or other documentation that specifically states who can or cannot document the Exam and MDM sections? Is there anywhere that states an RN or MA cannot document the Exam and/or MDM if the physician is signing off on the note?

Thanks.

May 5th, 2010 - nmaguire   2,606 

Rn

because they are not qualified providers.
http://www.trailblazerhealth.com/Publications/Meeting%20Minutes/E-MWBTQA09-30-09.pdf

May 5th, 2010 -

RN/MA documenting Exam/MDM

Thank you, the link is very helpful to have as documented proof.

May 5th, 2010 -

but remember

there is a difference between performing and recording. Some physicians employ scribes to document the questions and answers and record their physical exam findings- this is allowed.



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association